Utilization Review Nurse

2 months ago

Portland, United States Martins Point Health Care Full time

Join Martin's Point Health Care - an innovative, not-for-profit health care organization offering care and coverage to the people of Maine and beyond. As a joined force of "people caring for people," Martin's Point employees are on a mission to transform our health care system while creating a healthier community. Martin's Point employees enjoy an organizational culture of trust and respect, where our values - taking care of ourselves and others, continuous learning, helping each other, and having fun - are brought to life every day. Join us and find out for yourself why Martin's Point has been certified as a "Great Place to Work" since 2015.

Position Summary
The Utilization Review Nurse works as a member of a team responsible for ensuring the receipt of high quality, cost efficient medical outcomes for those enrollees with a need for inpatient/ outpatient authorizations.
This position receives and reviews prior authorization requests for specific inpatient and outpatient medical services, receives and reviews notification of emergent hospital admissions, completes inpatient concurrent review, establishes discharge plans, coordinates transitions of care to lower/higher levels of care, makes referrals for care management programs, and performs medical necessity reviews for retrospective authorization requests as well as claims disputes.
The Utilization Review Nurse will use appropriate governmental policies as well as specified clinical guidelines/ criteria to guide medical necessity reviews and will use effective relationship management, coordination of services, resource management, education, patient advocacy and related interventions to:
-Ensure members are receiving appropriate level of care
-Promote cost effective medical outcomes
-Prevent hospitalization/ readmissions when appropriate
-Promote decreased lengths of hospital stays when appropriate
-Provide for continuity of care
Job Description

Key Outcomes/Results:

  • Review prior authorization requests (prior authorization, concurrent review, and retrospective review) for medical necessity referring to Medical Director as needed for additional expertise and review.
  • Utilize evidenced-based criteria, governmental policies, and internal guidelines for medical necessity reviews.
  • Manage the review of medical claims disputes, records, and authorizations for billing, coding, and other compliance or reimbursement related issues
  • Collaborates with other members of the team, the MPHC Medical Directors, healthcare providers, and members to promote effective utilization of resources. This collaboration includes timely communications with in and out of network hospitals, post-acute care facilities, other providers, and internal departments to: authorize services, establish discharge plans, assist to coordinate effective, efficient transitions of care.
  • Coordinates referrals to Care Management, as appropriate.
  • Manages health care within the benefits structures per line of business and performs functions within compliance, contractual and accreditation regulations, e.g. Department of Defense, Centers for Medicaid and Medicare, NCQA, Employer contracts and state insurance regulations, as applicable. Maintains knowledge of applicable regulatory guidelines.
  • Completes all documentation of reviews and decisions, in appropriate systems, according to process/ compliance requirements and within timeliness standards.
  • Participates as a member of an interdisciplinary team in the Health Management Department
  • May be responsible for maintaining a caseload for concurrent cases/ assisting in caseload coverage for the team
  • Acts as a liaison to ensure the member is receiving the appropriate level of care at the appropriate place and time
  • Mentors new staff into case management role as assigned.
  • Assumes extra duties as assigned based on business needs.
  • Participates on committees, work groups, team rounds, and/or projects as designated.
  • Attends on-going training/continuing education, at a minimum annually, to maintain professional competency.
  • Assists in creation and updating of department Policies and Procedures.
  • Participates in quality initiatives and process improvements that reinforce best practice medical management programming and offerings.


Education/Experience:
  • Unrestricted state license as a Registered Nurse required; BSN preferred.
  • 3+ (total) years clinical nursing experience
  • Utilization management experience in a managed care or hospital environment required
  • Certification in managed care nursing or care management desired (CMCN or CCM)
Required License(s) and/or Certification(s):
  • Unrestricted state license as a Registered Nurse
Skills/Knowledge/Competencies (Behaviors):
  • Demonstrates an understanding of and alignment with Martin's Point Values.
  • Maintains current licensure and practices within scope of license for current state of residence.
  • Maintains contemporary knowledge of evidence - based guidelines and applies them consistently and appropriately.
  • Ability to analyze data metrics, outcomes and trends.
  • Excellent interpersonal, verbal and written communication skills
  • Critical thinking: can identify root causes and understands coordination of medical and clinical information
  • Ability to prioritize time and tasks efficiently and effectively
  • Ability to manage multiple demands
  • Ability to function independently
  • Computer proficiency in Microsoft Office products including Word, Excel, and Outlook

We are an equal opportunity/affirmative action employer.

Do you have a question about careers at Martin's Point Health Care? Contact us at: jobinquiries@martinspoint.org

  • Utilization Review Nurse

    2 weeks ago

    Portland, United States Martins Point Health Care Full time

    Join Martin's Point Health Care - an innovative, not-for-profit health care organization offering care and coverage to the people of Maine and beyond. As a joined force of "people caring for people," Martin's Point employees are on a mission to transform our health care system while creating a healthier community. Martin's Point employees enjoy an...

  • Utilization Review Nurse

    2 weeks ago

    Portland, United States Martin's Point Health Care Full time

    Join Martin's Point Health Care - an innovative, not-for-profit health care organization offering care and coverage to the people of Maine and beyond. As a joined force of "people caring for people," Martin's Point employees are on a mission to transform our health care system while creating a healthier community. Martin's Point employees enjoy an...

  • Utilization Review Nurse

    4 weeks ago

    Portland, Oregon, United States Martins Point Health Care Full time

    Job SummaryMartin's Point Health Care is seeking a skilled Utilization Review Nurse to join our team. As a key member of our Health Management Department, you will play a critical role in ensuring the receipt of high-quality, cost-efficient medical outcomes for our enrollees.Key ResponsibilitiesReview prior authorization requests for medical necessity,...

  • Utilization Review Nurse

    3 weeks ago

    Portland, Maine, United States Martins Point Health Care Full time

    At Martins Point Health Care, we're committed to transforming our healthcare system while creating a healthier community.As a Utilization Review Nurse, you'll be part of a team that ensures high-quality, cost-efficient medical outcomes for our enrollees.This role involves reviewing prior authorization requests, notifications of emergent hospital admissions,...

  • Maternal Nurse Reviewer

    4 weeks ago

    Portland, Oregon, United States Greenlife Healthcare Staffing Full time

    Job Title: Maternal Nurse ReviewerWe are seeking a skilled Maternal Nurse Reviewer to join our team at Greenlife Healthcare Staffing. As a Maternal Nurse Reviewer, you will be responsible for conducting clinical reviews of medical records from various sources, as well as other documents crucial to the reviews. Your expertise in obstetrical care and...

  • Maternal Nurse Reviewer

    3 months ago

    Portland, United States Greenlife Healthcare Staffing Part time $50

    Maternal Nurse Reviewer / Contract - Metropolitan Area (#25009)Minimum of 4 years clinical practice experience in a facility or community-based settingGreenlife Healthcare Staffing is currently seeking a Maternal Nurse Reviewer to fill an opening with a Non-profit organization located in New YorkRequirements of the Maternal Nurse Reviewer:Must be qualified...

  • Maternal Nurse Reviewer

    2 months ago

    Portland, United States Greenlife Healthcare Staffing Part time $50

    Maternal Nurse Reviewer / Contract - Metropolitan Area (#25009)Minimum of 4 years clinical practice experience in a facility or community-based settingGreenlife Healthcare Staffing is currently seeking a Maternal Nurse Reviewer to fill an opening with a Non-profit organization located in New YorkRequirements of the Maternal Nurse Reviewer:Must be qualified...

  • Registered Nurse Maternal Reviewer

    3 weeks ago

    Portland, United States Greenlife Healthcare Staffing Part time $50

    Registered Nurse Maternal Reviewer / Per Diem - Metropolitan Area (#25035)Greenlife Healthcare Staffing is currently seeking a Registered Nurse Maternal Reviewer to fill an opening with a Non-profit organization located in New YorkRequirements of the Maternal Nurse Reviewer:Must be qualified, and actively credentialed/registered in New York State (e.g....

  • Registered Nurse Maternal Reviewer

    3 months ago

    Portland, United States Greenlife Healthcare Staffing Part time $50

    Registered Nurse Maternal Reviewer / Per Diem - Metropolitan Area (#25035)Minimum of 2 years of clinical practice experience in pediatric/adolescent/reproductive health care is preferredGreenlife Healthcare Staffing is currently seeking a Registered Nurse Maternal Reviewer to fill an opening with a Non-profit organization located in New YorkRequirements of...

  • Campus Ambassador

    4 months ago

    Portland, United States The Princeton Review Full time

    Posting Details Job Details Description As The Princeton Review’s Campus Ambassador, you will be the vital link between your school campus and our local office. Campus Ambassadors are essential to our ability to forge new relationships and nurture existing ones. They serve as our primary points of contact with student groups, increase...

  • Document Review Attorney

    4 weeks ago

    Portland, Oregon, United States LHH Recruitment Solutions Full time

    Job DescriptionJob Title: Document Review Attorney (Japanese Fluency)Location: RemotePay Rate: $75/hr. (w2)Employment Type: ContractJob Description: LHH Recruitment Solutions is seeking highly skilled Document Review Attorneys to join their team for upcoming assignments of various durations. Candidates must possess a Juris Doctor (JD) degree, hold an active...

  • Prior Authorization RN Reviewer

    2 weeks ago

    Portland, United States Kaiser Permanente Full time

    Job Summary: To assist NWP clinicians, KPNW members and community clinicians in the coordination of medical services between Kaiser Permanente and community providers and facilities. Includes interfacing with NWP clinicians, community providers and members to ensure the member receives high quality, safe, efficient and timely medical services. Essential...

  • Logistics Coordinator for Utility Projects

    3 weeks ago

    Portland, Oregon, United States Insight Global Full time

    Job Summary: We are seeking a highly skilled Logistics Coordinator for Utility Projects to support our clients' projects team on a multi-year contract.The successful candidate will work within SAP to review and prepare reports, providing recommendations to utility project managers and the legal team. Prior experience and knowledge of utility materials such...

  • Health Evidence Review Commission Medical Director

    4 weeks ago

    Portland, Oregon, United States State of Oregon Full time

    Job SummaryThe Oregon Health Authority is seeking a highly skilled Health Evidence Review Commission Medical Director to join our team. As a key member of our Health Policy and Analytics team, you will be responsible for making evidence- and equity-based recommendations regarding coverage and prioritization of health services for the Health Evidence Review...

  • Utility Worker II Position

    4 weeks ago

    Portland, Oregon, United States City Of Tigard Full time

    Job Title: Utility Worker IIWe are seeking a skilled and experienced Utility Worker II to join our team at the City of Tigard. As a Utility Worker II, you will be responsible for maintaining and repairing our wastewater and storm collection systems, ensuring the safe and efficient operation of our infrastructure.Key Responsibilities:Install and repair catch...

  • Power Utility Design Supervisor

    3 weeks ago

    Portland, Oregon, United States Sigma Technologies (Ohio) Full time

    Job Type: Full-timeDescription: Sigma Technologies is a leading engineering and design firm with a strong presence in the power and telecommunications industries. As a Project Supervisor, you will play a crucial role in leading a team of professionals to deliver high-quality projects on time and within budget.Key Responsibilities:Provide first-level...

  • Telehealth Nurse

    4 weeks ago

    Portland, Maine, United States Travel Nurse Across America Full time

    Job Title: Telehealth Nurse Job Summary: We are seeking a highly skilled Telehealth Nurse to join our team at Travel Nurse Across America. As a Telehealth Nurse, you will provide critical care to patients in a remote setting, utilizing advanced technology to monitor and manage patient health. Responsibilities: * Provide high-quality patient care in a...

  • Principal T

    1 week ago

    Portland, Oregon, United States PacifiCorp Full time

    Job SummaryWe are seeking a highly skilled Principal T&D Specialist to join our team at PacifiCorp. The successful candidate will provide technical expertise in power utility electronic communications, investigate and resolve problem situations, and facilitate internal training for communications technicians and trainees.Key ResponsibilitiesProvide technical...

  • PACU RN Travel Nurse

    4 weeks ago

    Portland, Oregon, United States Travel Nurse Across America Full time

    Travel Nurse Across America is seeking a skilled Post Anesthesia Care Unit Registered Nurse to join our team for an immediate travel nurse opening in a dynamic healthcare environment. The ideal candidate will have 1-2 years of recent acute care experience and be proficient in providing observation and care for post-op patients as they recover from surgical...

  • Senior Project Manager

    1 week ago

    Portland, United States Ultimate Staffing Full time

    Location: Portland, ORPosition Type: Full-Time About the Company:Our client is a prominent firm in engineering and environmental solutions, specializing in impactful infrastructure projects across the U.S. Known for fostering innovation and community-focused growth, the company empowers employees to lead meaningful projects that improve regional water...